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I spent my elective working with Hillside Healthcare International. This is an American charity base in the Toledo district of Belize. The charity provided me with a variety of learning opportunities in different settings: a free standing clinic, mobile clinics into remote villages, community education programmes, and home health.

The aim of my elective was to enhance my medical knowledge, to gain practical knowledge of tropical diseases common to Belize and to gain all round experience interacting with patients in a different foreign country. I also wanted to experience working in a resource poor environment.

The Toledo district is the most southern district in Belize. It is also the most rural and the poorest. Most emergency care, maternity services, paediatrics and some chronic disease management is free and provided by the Ministry of Health. Hillside gets some of its medicines from the Ministry of Health free and works alongside the Ministry. Hillside also receives donations (usually from the USA) of medicines.

Hillside provides the local communities with medical care including pharmacy, nursing and physiotherapy. Whilst there I was able to actively be a member of the multidisciplinary team working alongside other medical students, pharmacy students and physiotherapy students as well as our qualified preceptors.

Whilst at the free standing clinic we would see patients from all walks of life – locals and tourists. All the services that Hillside provides are completely free to everyone and we never turned anybody away. The nearest hospital was a 20 minute drive away; this has an emergency room, 5 doctors, an ophthalmologist and the only dentist in the district. However, the nearest general surgeon was in Dangriga (20 minute flight away), and for most specialists we needed to refer to Belize City. Consultations in Belize City are not free and would often be too expensive for most of our patients). The lack of resources locally did limit what we were able to do but we made the most of what we had available. Furthermore some patients were reluctant to go to the hospital in Punta Gorda either because of the cost of the bus and/or because of a previous bad experience.

As well as the free standing clinic, I was also given the opportunity to go on many mobile clinics. This involved packing all our equipment and medicines into a jeep and driving (sometimes for about 3 hours) to the villages. When we arrived we would set up a pop-up clinic and see patients in their own village. I visited every village on the map apart from San Bonito Poite (which I did not reach due to bad weather and impassable roads). This provided me with a unique opportunity to not only visit the rural villages but also see the country and its population at work.

For many patients in Belize going to the doctor means taking the day off work and paying to get there (usually by bus). This means that many people do not come to the doctor unless it’s absolutely necessary. This is why rather than waiting for the patients to come to us, we went to the patients. Whilst in the villages we saw patients that otherwise would not have sought medical attention.

In the villages we were unable to perform blood tests or get x rays. The only tests available to us were blood sugar monitoring, urine dips and pregnancy tests. Not only was this a very valuable experience as it allowed me to see what rural life is like in Belize but it also showed me the importance of taking a good history and examination as I had to rely on that rather than tests to diagnose and treat. Furthermore the only medications/treatments we had were the ones we brought with us. This meant that often we would substitute medicines and use the second/third line treatments or use medications off license.

Another aspect of my time at Hillside was the home visits with the nurse. This involved going to patients homes, accessing them and treating them. Mostly these patients were “palliative” meaning that they had a long term condition that was not going to get better (mainly because they could not afford the treatment). Often this meant seeing patients who back home in the UK would be treated and cured, which at points made me quite emotional.

Furthermore we would visit patients who required wound care for diabetic ulcers or the disabled who were unable to come to the clinic. Not only did this show me how privileged we are to have the NHS but it also allowed me to see into people’s homes. This opened my eyes to how the local people lived and showed me the contrast between living conditions within Belize and compared to here in the UK.

In addition to the more clinical work, Hillside also gave me the opportunity to educate the public about health (mainly diabetes and hypertension) at health fairs in some of the villages. This involved us going into the communities, taking blood pressures and sugars, and providing advice and information on diet etc. This added another aspect to my elective; I learnt the importance of education, something that back home we take for granted. Most people did not know what high blood pressure was or how diabetes can affect their lives. We also provided contraception advice and talked about the importance of family planning. What struck me most whilst taking part in these fairs is that a proportion of the population are from Mayan descent and speak Ketchi (with some limited English), and there are no words in Ketchi for family planning or the anatomy of the female reproductive tract. This made educating them about family planning options particularly difficult and challenging not only for me but also for the clinic staff who acted as translators as well as performing their own tasks.

Cases

The majority of the cases that I saw whilst on my elective were what is most common in Belize: diabetes, heart disease and stroke (1) but I also saw some more unusual diseases that I would not see back in the UK, such as scabies, worms and Chikunguya. Some of these cases really stood out for me and provided me with important lessons.

There is very little mental health provision in the Toledo district of Belize. There is one psychiatric nurse for the whole district, no psychiatrists and no mental health hospitals. An American couple came into the clinic; the husband had already been diagnosed with depression and started fluoxetine six weeks before. He was also an alcoholic and gets violent when he is drunk. The couple had just moved to Belize to set up an ideal life but everything going wrong and they were both under a significant amount of stress. The wife was self-harming as she did not know what to do and her husband has attempted suicide in the past and has current suicidal thoughts. I was very worried about the couple and did my best to counsel them and to offer any help I could. If this had been in the UK I would have wanted to admit them both for psychiatric care but I was unable to do this. The best that I could do was to start the wife on an antidepressant, make them both promise not to act on their suicidal thoughts and ask them to come back next week to have another discussion. Neither returned. I thought about suggesting that they return to the USA where they have some family and friends to support them but I do understand that this could be considered a step backwards and that they could feel like they were giving up. On reflection, I believe that I did the best I could in the situation. I hope that they do return before anything serious happens.

When I first arrived in Belize I was expecting to see many vector borne diseases such as dengue fever, zika virus and malaria. However this was not the case. I saw only one of two patients with suspected Dengue/Zika. This is mainly due to the efforts of the vector control department. I spent a morning with them: we went into gardens and educated people about the best ways to prevent mosquito breeding. We also put tablets in still buckets of water to kill any existing mosquito larvae.

Whilst at the clinic I saw a young man who came in with a rash, sore throat, joint pains and fever. He had the classic villiform rash and a low grade fever. The fever, sore throat and joint pains started three days prior to the rash. We were unsure of the exact diagnosis (Zika or Dengue) as his presentation fitted both. We sent off some blood samples – these take up to eight weeks to get results as they are sent to Barbados – for epidemiological reasons and then treated him symptomatically. We warned him and his wife (who was asymptomatic) to use two methods of contraception for the next six months as a precaution. What surprised me most about this case was how well he seemed. He only came in because he had developed a very impressive rash overnight, he just “felt like he had flu”.

Reflection

I really enjoyed my elective and feel that I gained immensely from it. As mentioned above I feel like not only did I enhance my medical knowledge, but also I gained many insights into what it is like to live and work in poor communities. I was fascinated to see how people live in Belize and know that what I have learned will stand me in good stead in my future practice both at home and abroad. I now want to go back to the clinic and precept in my F3 year if I am able to do so!

References

1. World Health Organization. Belize: WHO statistical profile. [Online]. 2015. Accessed 20th September 2016. Available from; http://www.who.int/gho/countries/blz.pdf?ua=1 .

David Gold
Leeds

The 6th Anglo Israeli Cardiovascular Symposium took place on the 7-8th December 2016 in the beautiful setting of the Rimmonim Galei Kinneret Hotel, with a view over Lake Tiberias.

The Symposium displayed some of the very best of British and Israeli cardiology. A variety of wonderful speakers and leaders in their fields provided updates on their latest research and there were important take-home messages for clinical practice. Highlights included the talks given by Prof Ulrich Sigwart (University of Geneva, Switzerland) who spoke about alcohol septal ablation in hypertrophic obstructive cardiomyopathy (HOCM); Prof Sanjay Sharma (St George’s Hospital, London) who gave an update on the electrocardiographs (ECG) ) of young athletes: and Prof Michael Glikson (Sheba Hospital, Ramat Gan, Israel) who provided important lessons that could be learned from the comprehensive Israeli implantable cardioverter – defibrillator (ICD) registry.

The symposium provided an excellent opportunity for conversation and relationship building between Israeli and British cardiologists. The Israeli participants included both Jewish and non-Jewish doctors – the conference was opened by Dr. Ofer Amir, Director of Cardiology at Poriya Medical Centre, which was the hosting hospital, and in his talk he explained how Muslim, Christian and Jewish doctors in his department work together seamlessly, provide an example of religious co-existence in Israel. He said that there are Palestinian cardiologists in training at Poriya hospital and then transferring their expertise upon their return to their home hospital.

As an FY1 doctor, embarking upon a career in cardiology, I was honoured and delighted to have been invited to attend the conference. I thoroughly enjoyed both the subject matter, and the opportunity for networking with British and Israeli cardiologists alike. I feel that this opportunity will prove beneficial to me when embarking on specialty training in the UK, and will also allow me to consider future potential collaborative projects with contacts in Israel. These symposia, creating and fostering connections between Israeli and British cardiologists, are a wonderful opportunity and I would be delighted to help organise them in the future.

(Dr) Brett Bernstein

FY1, North Middlesex University Hospital

Having undertaken the majority of my final year elective at Great Ormond Street Hospital, I was keen to spend some time in Israel. I joined the Hadassah Paediatrics Department on the Ein Kerem campus for a week in October 2012, with the intention of learning more about the Israeli medical system in general and paediatrics in particular, with a view to emigrating to Israel and specialising in paediatrics.

I stepped off the El Al night flight early on Sunday morning, and made my way bleary eyed to Ein Kerem, Jerusalem, where I was welcomed by Ayelet, the elective organiser, a medical student herself. I was immediately struck by the hospital’s pleasant appearance, replete with a shopping mall, which compared starkly with the somewhat dreary-looking NHS hospitals we often find ourselves. The paediatrics inpatient department occupies a floor in the relatively newly built “Mother and Child Pavilion”, a modern building linked to the main hospital, with outpatient clinics, obstetrics, and neonatal and paediatric intensive care on the other floors.

The day began at 8am, when junior and senior staff alike meet to handover patients from the previous night, and to discuss management of the more difficult cases. On several days of the week, this was followed by departmental teaching, either given by one of the trainees or by a clinician from elsewhere. I was very impressed by the standard of material presented, which I felt surpassed that of comparable meetings I have attended in the paediatrics departments of the North Middlesex and UCL Hospitals. Interestingly, Israeli doctors tend to present in Hebrew with a smattering of English phrases, yet their lecture slides are almost entirely in English. Of note, several senior doctors not responsible for ward cover that week also attended these morning meetings to contribute to discussions on patients’ care, something I have not observed in the UK.

The doctors split into their two ‘teams’ to carry out ward work prior to the ward round starting at 11am. It is worth mentioning that senior doctors responsible for patients on the ward are all subspecialists, as the concept of a general hospital paediatrician does not exist in Israel as it does in the UK. The majority of Israeli paediatricians are generalists working in the community, and a minority subspecialise and form the corpus of hospital paediatricians. For example, the consultant I joined is a paediatric neurologist. Nonetheless, all subspecialists must maintain their competence and knowledge of general paediatrics as patients under their care while they are responsible for the ward cover the gamut of general paediatrics.

While the ward round was comprehensive, it reflected a style of practice somewhat outdated (for the better) in the UK. The team would enter a patient’s room and have a discussion about their care without involving the patient or their parents, and without any introductions from the doctors. Questions would be fired at the parent to clarify the history, and often the team would leave the room without providing any update on the patient’s progress. I felt that the communication skills and bedside manner in Israel were somewhat lacking, although my Israeli medical student counterparts assured me that this is starting to change.

I joined the Hebrew University final year medical students on the ward for their teaching. They received consultant teaching most days of the week (UCL take note!), which was to a high standard and was similar in style to what I was used to. I found that my knowledge was generally similar to the Israeli students although they certainly had a better grasp of pharmacology than UCL medical students.

I also had the opportunity to join some clinics, which generally were only scheduled in the morning. I joined Dr David Zangen, a paediatric endocrinologist whom Prof Katz had introduced us to during a Student JMA tour in 2009, and Professor Michael Wilschanski, a British paediatric gastroenterologist who had studied at the Royal Free Medical School.

The working day pleasantly ends at 4pm, after which the night shift team takes over in A & E and on the wards (they do a 26-hour shift), although I had the impression that many doctors work in community clinics afterwards to supplement their modest income.

In terms of patient demographics, the majority were Haredi or Arab, with the remainder being secular and ‘national religious’ Jews, which reflects the current trends in the changing Jerusalem population. It was immensely useful to have Arab and Russian doctors on the team in overcoming language barriers.

Finally, my description would not be complete if I did not describe the unique experience of working in an Israeli hospital environment. Looking out of the windows at the panoramic views of the Jerusalem hills surrounding the hospital (see the image below) was emotionally stirring and made day-to-day life working there feel more meaningful. I felt a bond with staff and patients alike unparalleled during the past few years I have spent in UK hospitals; joining the hospital synagogue services where one would pray alongside all sorts of people from patients and doctors to hospital porters and chefs had a very natural feel to it.

I would like to thank the Jewish Medical Association for their generosity in supporting me to have such an enjoyable and worthwhile week in Hadassah, Ein Kerem.

Leo Arkush
UCL

I spent my elective in autumn of 2008 at Hadassah, Ein Karem, Jerusalem for 6 weeks in the departments of Internal Medicine and Neurology. Both departments had a heavy and varied case load, and included HDU bays with intubated patients. I attended and contributed to lengthy and discursive ward rounds, and attended departmental meetings and journal clubs. I vastly improved my medical Hebrew and I compiled a dictionary of over 800 words intended for the JMA(UK) electives’ website. In Israel, medical students are taken seriously and are expected to be well read and so I learnt a lot of medicine as well as deepening my understanding of Israeli medical care.

Non-medical highlights of my elective included the mandate-period Rockefeller Antiquities Museum, a debate on the state of Israeli democracy launching a book by Shulamit Aloni, and an “Alternative Tourism Group” trip to Bethlehem, Dheisheh and Hebron.

Bernard Freudenthal
Final Year Medical Student – University College London

During my internship, most mornings I would arrive at the hospital at about 8am for the paediatric ICU ward round. This involved the ICU consultant, a couple of residents/interns, nurses and two Chinese doctors who were being trained in Israel by SACH. The Israelis would obviously speak among themselves in Hebrew, and although I do speak basic Hebrew, I could not keep up with their fast, medically-based conversations. The Chinese doctors certainly could not either. So the ward rounds would be conducted—often with a polite reminder from me—in English.

Some mornings and afternoons I would go to the operating theatre, where I saw cardiac surgery being performed on children with congenital problems such as Tetralogy of Fallot or septal defects (i.e. problems with the architecture of the heart and its great vessels). At other times I would attend the paediatric cardiology clinic where children were seen for pre-operative assessment and for follow-up. I saw lots of echocardiography (cardiac ultrasound) being performed there. Dr Abrahams, a friendly Ethiopian doctor being subspecialty trained in paediatric cardiology as part of SACH, was based mostly in the paediatric cardiology clinic and, like the other doctors, was always happy to teach me when time allowed. The clinic was a fun place to be. Many of the children in the waiting room would be running around, chasing each other, dancing, posing for photographs, or generally being boisterous, which was great considering many of them could not do this before their operations; their heart simply had not been strong enough. That goes to show just how much of a difference SACH is making to their lives, both in terms of quality and longevity.

I saw lots of patients but the one that stuck in my mind the most was a Kurdish child (about 10 years old) on the paediatric high dependency unit, and his mother. Unfortunately, his congenital heart condition and surgery had been more complicated than normal and he was very unwell. His mother was sat by his bedside all day long (possibly all night long). Neither the child nor his mother spoke a word of Hebrew, English or Arabic, and none of the staff spoke Kurdish. All communications were done by gesticulation. I cannot imagine how frustrating this must have been for them. They cannot possibly have fully understood what was going on in terms of the child’s progress. The boy was very pale, often tearful, and his mother often had a tired and forlorn expression on her face. A couple of times a day I went to say hello (I would just smile and wave), and sometimes would get a smile out of them. His mother would often get out of her chair to stand when I arrived. She would do this for every doctor, nurse or volunteer, seemingly out of respect. Every time I tried to intimate that this was unnecessary but she still did it. Anyway, on a positive note, towards the end of my internship the boy was looking much better. He was more ‘smiley’, and the colour had returned to him. His mother was also visibly happier…and so was I.

On another note, it was amusing to see how the quintessentially casual, laid back Israeli attitude was just as prominent in the hospital as outside of it. This held true even in the hi-tech and intense environment of the ICU where the medical care has to be—and of course is—razor sharp. Personally, I like the fact that the ICU consultant wore jeans and a t-shirt, and how I was allowed to wear casual clothes. In that particular respect, it could not be further removed from the hospitals in the UK, where every aspect of clothing is subject to ‘hospital policy’, down to the jewellery, watches and ties that are worn (or more accurately are not worn). I thought the cleanliness and attention to medical hygiene was excellent in the Wolfson Hospital, and there appeared to be no rampant nosocomial infection epidemic, even though the doctors were allowed to wear watches. All in all, I thought the relaxed environment had a very positive impact on the staff, the patients and their families. There were lots of smiles all round.

As part of the internship, I spent one day in the SACH House, where I joined in with the children playing games and generally being downright silly, along with some Canadian girls and an another English medical student, who were volunteering there. Again, it was amazing to see the mothers of the children from such vastly different countries and cultures all socialising in the kitchen whilst they were making dinner.

All in all I had a great time during my SACH internship. It was fun, inspiring and educational, and you really have to see it for yourself to understand what a special atmosphere there is throughout the SACH infrastructure. As a medical student with an avid interest in cardiovascular health and disease, it was a fantastic experience, and as a Jew I feel very proud of what’s being done in Israel for this huge multicultural spectrum of children. I would like to thank everybody at SACH for allowing me such a wonderful opportunity, and the Jewish Medical Association (UK) for their generous scholarship. I intend to visit again next time I am in Israel, and I would encourage you to do the same.

Warren Backman
University College London

I spent four weeks on the neonatal intensive care unit (NICU) and the last two weeks with Ambulance Victoria’s Paediatric, Infant and Perinatal Emergency Retrieval (PIPER) team at the Royal Children’s Hospital in Melbourne, Australia.

On the very busy neonatal ICU I was quite self-directed with clinical opportunities as and when they presented themselves. I learnt how to cannulate neonates and take heel prick bloods and capillary blood gases, which the nurses taught me how to do on the wards and have since been incredibly useful skills for my foundation jobs.

Typically my day was around 8am-4pm. I attended handover and ward rounds in the morning and then helped the junior doctors with their jobs. I was able to sit in on family meetings and interesting psychosocial meetings with social workers, music therapists, physiotherapists and OTs. I also joined the teaching day for the junior doctors, participating in SIM sessions and physiology teaching. There was also a fascinating NICU specialist ethicist who I observed for a little bit. On NICU there were also bedside surgeries (e.g. exploratory laparotomies) as RCH is the main centre for Paediatric Surgery in Melbourne which I was able to observe. The hospital also hosts regular lunchtime lectures and Grand Rounds for anyone to attend which were interesting and useful for those interested in Paediatrics.

Early on I was offered opportunities to get involved with academic research. I completed an audit as part of a wider research project at the RCH looking at the long-term neurodevelopmental outcomes at 2, 5 and 8 years of neonates born with features of VACTERL association which I really enjoyed and found very interesting; in particular I looked at the incidence of multiple VACTERL association in neonates admitted to NICU with tracheo-oesophageal fistula or oesophageal atresia over a ten year period. I have since presented this audit as a poster at a conference at the John Radcliffe Hospital, Oxford which was very well received.

For my last two weeks I joined the Neonate Emergency Transport service, which retrieves unwell neonates from all over Victoria (and sometimes beyond) and brings them to tertiary centres for further investigation and management and/or surgery. This was an incredible experience as I got to join the team on trips to other hospitals in the city and outskirts as well as on aeroplane trips to hospitals further away from Melbourne in Victoria to collect patients. From a learning perspective it was a bit different from the skills-based experience on NICU as it was more acute and more case-based around the babies we were retrieving. My NETS experience was not part of my original elective plan, however I asked if I could spend some time with the team after observing their handover of their patients to the NICU and I enjoyed my first day with them so much I spent another two weeks there!

I applied for this elective placement at the Royal Children’s Hospital (RCH) through the University of Melbourne external students’ elective programme and I would highly recommend it to anyone interested in pursuing a career in Paediatrics.

Sarah Simons
Nottingham